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→Conclusion
<p style="text-align:justify;">The general causative factors of shiroroga are suppression of natural urges, day sleep, insomnia, intoxication, talking too loudly, exposure to frost, exposure to wind from the front, excessive indulgence in sexual activity, inhalation of unwholesome smell, exposure to dust, smoke, cold and sun; over eating of heavy, sour, and green food, use of very cold water, trauma to the head, formation of products of improper digestion and metabolism in the body (i.e. ama), excessive weeping or suppression of tears, cloudy weather, irritation of mind and anomalous climate.. These factors provoke or vitiate vata, affecting rakta in the head leading to shiroroga with various symptoms. [Cha. Sa. Sutra Sthana 17/8-11]</p>
<p style="text-align:justify;">The general causative factors of shiroroga are suppression of natural urges, day sleep, insomnia, intoxication, talking too loudly, exposure to frost, exposure to wind from the front, excessive indulgence in sexual activity, inhalation of unwholesome smell, exposure to dust, smoke, cold and sun; over eating of heavy, sour, and green food, use of very cold water, trauma to the head, formation of products of improper digestion and metabolism in the body (i.e. ama), excessive weeping or suppression of tears, cloudy weather, irritation of mind and anomalous climate.. These factors provoke or vitiate vata, affecting rakta in the head leading to shiroroga with various symptoms. [Cha. Sa. Sutra Sthana 17/8-11]</p>
== Classification of diseases in shiras (shiro roga) ==
<p style="text-align:justify;">The diseases in head region are classified based on the dominance of vitiated dosha. Acharya Charak in Sutra Sthana mentioned principally 5 types of shiro roga [Cha. Sa. Sutra Sthana 19/3] and well explained the same in Chikitsa sthana.[Cha. Sa. Chikitsa Sthana 26/118]</p>
<ol style="text-align:justify;"><li style="font-weight: bold;">Vataja shiroroga<span style="font-weight: normal;"><br/>Indulgence in loud speech, excessive talk, strong drinks, keeping awake till late at night, exposure to cold wind, excessive sexual acts, suppression of natural physical urges, fasting, trauma, excessive/strong vamana or virechana, excessive weeping, grief, fear, terror and severe emaciation leads to the provocation of vata which by affecting the vessels of the head gets further provoked and produces severe pain in head. The vata-dominant diseases in the head are characterized by intense pain in the temple region, mid of eyebrows, pain in the forehead, dizziness, and stiffness in the neck region. Use of hot and unctuous things provides relief in vata type of headache. [Cha. Sa. Sutra Sthana 17/19-21]<br/>Primary treatment includes abhyanga [anointing with oil], swedana [steam therapy], nasya [oil instillation through nostrils], diet management and, poultice application. [Cha. Sa. Chikitsa Sthana 26/158]</span></li>
<li style="font-weight: bold;">Pittaja shiroroga<span style="font-weight: normal;"><br/>Excessive use of pungent, sour, salty, and alkali substances and wine, exposure to sun (or heat), and anger lead to the provocation of pitta, which by lodging in the head, produces pitta-dominant diseases of the head. The pitta dominant diseases in the head are characterized by a burning sensation overhead region, headache, burning sensation in the eyes, and excessive perspiration. [Cha. Sa. Sutra Sthana 17/22-23]<br/>Primary treatment includes aspect – intake of medicated ghee, milk etc. and application of poultices, herbal ointments/ pastes, nasya with ghee. [Cha. Sa. Chikitsa Sthana 26/176]</span></li>
<li style="font-weight: bold;">Kaphaja shiro roga<span style="font-weight: normal;"><br/>Due to sedentary lifestyle, excessive sleep, indulgence in heavy and unctuous meals, or excessive food intake, kapha gets provoked in the head and produces kaphaj shiro roga. The kapha-dominant diseases in the head are characterized by constant dull headache, heaviness of the head, stiffness, extreme laziness, and loss of appetite. [Cha. Sa. Sutra Sthana 17/24-25]Primary treatment includes dhumapana [medicated smoke], diet management which reduces kapha dosha, basti karma, administration of old preserved medicated ghee, agni karma [cauterization method].[Cha. Sa. Chikitsa Sthana 26/180]</span></li>
<li style="font-weight: bold;">Tridoshaja shiro roga<span style="font-weight: normal;"><br/>The diseases with vitiation of three dosha in head are characterized by headache, tremors, burning sensation, excessive thirst. [Cha. Sa. Sutra Sthana 17/26] Primary treatment includes all the above management principles applied accordingly and intake of purana ghruta. [Su. Sa. Uttartantra 26/24]</span></li>
<li style="font-weight: bold;">Krimija shiroroga<span style="font-weight: normal;"><br/>When a person with provoked dosha indulges in excessive intake of sesame, milk, molasses, takes meals even when previous meal has not properly digested, eats putrefied or promiscuous food, and/or takes incompatible diet - it causes pathological discharges of rakta, kapha and mamsa, wherein parasites are produced, leading to krimija shiroroga with dreadful symptoms and feels as if, the patient suffers from piercing, cutting or aching pains in the head with itching, swelling, foul smell and detectable parasites. [Cha. Sa. Sutra Sthana 17/27-29] Primary treatment includes removal of the worms/micro-organisms by strong medicated nasya [instillation of oil, liquid, powders etc through nostrils] and medicines to counteract them.[Su. Sa. Uttartantra 26/28]</span></li></ol>
== Other diseases ==
<p style="text-align:justify;">Injury to the shiras leads to manyastambha (stiffness of neck), ardita (hemiplegia with facial palsy), chakshuvibhrama (improper movements of eyeball/lesions in sight), moha (a state of confusion), udveshtana (twisting pain in the head), cheshtanasha (loss of body functions), kasa (cough), shwasa (breathlessness), hanugraha (stiffness of jaw), muka (dumbness), gadgada (hoarseness of voice), akshinimilana (ptosis), gandaspandana (twitching in cheek), jrumbhana (excessive yawning), lalasrava (dribbling of saliva), svarahani (aphonia), vadana jihmatva (deviation of face) etc. [Cha. Sa. Siddhi Sthana 9/10]<br/>Acharya Sushruta described eleven types of diseases occurring in head region. [Su. Sa. Uttartantra 25/3-16]</p>
<ol style="text-align:justify;"><li>Vataja —A headache of non-specific aetiology that is markedly aggravated at night and is relieved by pressure and fomentations.</li>
<li>Pittaja—The headache in which the head, eyes, and nose feel burning and fuming and as if they are full of burning charcoal, and which is relieved by cold applications and also at night, is said to originate from vitiated pitta.</li>
<li>Kaphaja—A headache in which the head and throat are felt as if filled with kapha and are characterized by heaviness, stiffness, coldness, and swelling of the orbit and the face.</li>
<li>Sannipātaja - Arising from the combination of all the three doshas shows mixed features of all above types.</li>
<li>Raktaja - Having the characteristics of pittaja headache with hyperaesthesia of the head in addition.</li>
<li>Kshayaja - The decrease of unctuous constituents and kapha in the head, as a result of trauma to the head, produces headache arising from depletion of tissues, which is very severe, causing excruciating pain and is increased by sudation, vomiting, fumigation, snuffing and blood-letting therapies.</li>
<li>Krumija - A person who suffers from a severe pricking headache with a feeling of being eaten up or of something cracking inside and who also has watery discharge from the nose mixed with blood.</li>
<li>Suryavarta - The headache which starts mildly in the regions of the eyes and the eyebrows with the sunrise, gradually gains momentum and increases with the sun (going up) and finally subsides as the sun sets and which is sometimes relieved by cold measures and sometimes by hot measures, is described as suryavarta. It is sannipataja in nature, and is extremely troublesome.</li>
<li>Anantavata - When all the three dosas in a vitiated condition affect the manya and produce severe pain in the back of the neck (ghata) which is particularly referred to the region of eyes, the eyebrows and the temples where it is localised, producing twitching on the sides of the cheek, lock jaw and many other diseases of the eye; such a condition is described as anantavāta.</li>
<li>Ardhavabhedaka - The person who has a severe headache of bursting, pricking and spinning types confined to half of the head only and the attacks tend to come every fortnight, ten days or suddenly (irregularly), is said to have ardhāvabhedaka. It is supposed to be sannipataja in origin.</li>
<li>Shankhaka - The troublesome disease in which exacerbated vata localised to the region of the temples and followed by kapha, pitta and rakta, produces excruciating pain in the head particularly in the temples, is termed shankhaka.</li></ol>
<p style="text-align:justify;">Acharya vagbhatta mentioned about following diseases in shiroroga vigyaniya adhyaya:
Shirastapa, ardhavbhedaka (affecting half of the head), krimija shiro roga, shira kampa (predominance of vata produces shaking of the head), shankhaka (predominance of pitta, associated with blood causes swelling in the temples along with other symptoms), suryavarta (vata followed by pitta, causes severe throbbing pain in the temples, eye brows and forehead beginning in the head), upshirshaka (the scalp when in the womb, gets vitiated by vata, develops a swelling of the same colour of the skin and is devoid of pain), pitika, arunshika (eruptions) on the scalp caused due to pitta, blood, kapha and worms, darunaka(caused due to vitiation of kapha and vata produce itching, loss of hair, loss of tactile sensation on the scalp, dryness and causing minute cracks in the skin), indralupta (the pitta present in the hair follicles along with vata makes the hair to fall off while the kapha along with blood blocks the orifices of the hair follicles and there is no growth of new hair), khalita (falling of hair due to vata causes scalp to look as though it has been burnt by fire. These are caused due to vitiation of the pitta studded with a network of veins that are thick and are of the same colour as that of the skin) and palita (the heat of the body provoked by grief, exertion and anger, moving on to the head along with the doshas eliminates the hair color to make them gray). [Ash. hr. Uttar sthana 23/6-29]</p>
== Diseases with headache as clinical feature ==
Shirahshool (Headache) occurs in following conditions also:<br/>Due to suppression of urge of defaecation and sneezing [Cha. Sa. Sutra Sthana 7/8,16]
* Vaataja gulma [Cha. Sa. Nidana Sthana 3/7]
* Vatapitta jwar [Cha. Sa. Chikitsa Sthana 3/85]
* Sannipata jwar [Cha. Sa. Chikitsa Sthana 3/103]
* Ajeerna [Cha. Sa. Chikitsa Sthana 15/45]
* Visuchika [Su. Sa. Uttartantra 56/6]
* Karna pratinaha [Su. Sa. Uttartantra 20/12]
== Diagnostic tools and investigations ==
Following investigations support to diagnose diseases of head region:
# Complete blood count
# X-ray skull
# Electroencephalography (EEG)
# Computerized tomography (CT) scan of head
# Magnetic resonance imaging (MRI) scan of brain
== Preventive measures ==
Ayurveda advocates several preventive measures to maintain the health of shiras:
<ul style="text-align:justify;list-style-type:none;"><li style="font-weight: bold;">Nasya - <span style="font-weight: normal;">The administration of medicated oil or substances through the nasal passage, is recommended during specific seasons to prevent shiro roga. It helps prevent hair fall, stiffness of the neck, headaches, and facial paralysis. [Cha. Sa. Sutra Sthana 5/60]<br/>Anointing the head with oil is called Murdha taila. It is of four kinds: pouring oil down on the head (parisheka) smearing oil and mild massage (abhyanga), keeping cloth soaked in oil (picu) and basti or sirobasti, each successive type being more effective than the former.
</span></li>
<li style="font-weight: bold;">Shiro-abhyanga - <span style="font-weight: normal;">Smearing oil and application of mild massage is abhyanga. In cases of dryness, itching and dirtiness can be treated by oil application.</span></li>
<li style="font-weight: bold;">Parisheka - <span style="font-weight: normal;">Pouring of oil is parisheka. In the case of ulcerations of the scalp, headache, burning sensation, wounds, and suppurations of the scalp is helped by oil application.</span></li>
<li style="font-weight: bold;">Shiropichu - <span style="font-weight: normal;">Oil-soaked cloth (Pichu) could be applied to stop falling hair, cracking of the skin and feeling of burning sensation as well as in cases of blocked vision.</span></li>
<li style="font-weight: bold;">Shiro basti - <span style="font-weight: normal;">Oil application on the head is basti. In the case of loss of sensation of the scalp, facial palsy, loss of sleep, dryness of the nose and mouth, blindness and diseases of the head, is helped by basti. [Ash. hr. Sutra sthana 22/23-26]</span></li>
<li style="font-weight: bold;">Shirodhara - <span style="font-weight: normal;">Shirodhara is an ancient healing procedure that incvolves pouring liquid on the forehead from a definite height for a specific period allowing the liquid to run through the scalp and into the hair. This is a subtype of murdhataila along with shiro abhyanga, pichu, and shiro basti. </span></li></ul>
== Standard treatment protocol ==
As per ministry of Ayush, treatment is at three levels based upon the availability of health facility and clinical condition of the patient:
'''Level 1''' -: At solo ayurveda physician clinic/PHC
In the initial stage when the patient is having signs and symptoms of shirashoola, following drugs may be given:
{| class="wikitable"
|Drugs
|Dose
|-
|Pathyadi Kwatha<ref name="ref5">Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part II (4:15), 2000</ref>
|20ml twice a day with guda
|-
|Gau ghrita
|3 drops in each nostril 4 times a day
|}
Referral criteria: If patient is not responding to above mentioned management within 5 or 7 days and if signs and symptoms indicate need for further investigations.
'''Level 2''': CHC’s or small hospitals with basic facilities,
in addition to the management mentioned in Level 1, few of the following drugs may be added as per the requirement and status of the patient.
{| class="wikitable"
!'''Drugs'''
!'''Dose'''
|-
|Shirahshooladi Vajra Rasa<ref name="ref6">Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part II (16:59), 2000 </ref>
|2 tabs twice a day with normal water
|-
|Shadabindu Taila Nasya<ref name="ref7">Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part I (8:60), 2000</ref>
|3 drops in each nostril once a day
|-
|Dashamoola Taila<ref name="ref8">Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part II (8:6), 2000</ref> for Abhyanga on scalp
|15 ml once a day
|}
Referral criteria: If patient is not responding to above mentioned management within 10 days or signs and symptoms become more acute, patient should be referred for panchakarma therapy.
'''Level 3''': Ayurveda hospitals at institutional level or district hospital / integrated ayurvedic hospitals.
In addition to the management of Level 1 and Level-2, panchakarma procedures is indicated.
{| class="wikitable"
!S.no.
!Type of Shiroroga
!Treatment
|-
|1.
|Vataja shiroroga
|
* Shirodhara with Luke warm cow milk prepared with Vata pacifying medicines
* Upanaha sweda with krishara
* Marsha nasya with Tila Taila prepared with Vata pacifying medicines
|-
|2.
|Pittaja Shiroroga
|
* Shirodhara with cold milk, sugarcane juice, madhu jala, mastu
* Marsha nasya with Pitta pacifying aushadha sidhdha ghrita i.e. kshira sarpi, jeevaniya ghrita
* Virechana with trivrita avaleha or ghrita
|-
|3.
|Kaphaj Shiroroga
|
* Pradhaman Nasya with Katphala Churna
* Shirolepa with Trivrittadi Lepa
* Fomentation with Water
|-
|4.
|Tridoshaja Shiroroga
|
* Above mentioned treatment as per predominant Dosha
* To drink old Ghrita is especially advocated.
|-
|5.
|Raktaja Shiroroga
|
* As per Pittaja Shiroroga
|-
|6.
|Kshayaja Shiroroga
|
* Ghritapana
* Marsha Nasya with Vataghna Aushadh Siddha Taila
|-
|7.
|Suryavarta
|
* Ghritapana
* Marsh Nasya with Jeevaniya Ghrita
* Shirodhara with lukewarm cow milk prepared with Vataghna medicines
* Shirobasti with Luke warm cow milk
|-
|8.
|Ardhavabhedaka
|
* Same as treatment of Suryavarta
* Avapida Nasya with Shirisha Moola/Phala or Vacha & Pippali
|-
|9.
|Anantavata
|
* Same as treatment of Suryavarta
|-
|10.
|Shankhaka
|
* Marsha Nasya with Vataghnaaushadh Sidhdha Ghrita
* Shirolepa Shatavaryadi Churna[Su. Uttartantra 26/39]
|}
== Pathya-Apathya (Diet and life style education) ==
'''Pathya:'''
'''Ahara (food articles):''' Freshly cooked, easily digestible diet i.e. Purana Ghrita, Shali/ Shashtika rice, cow milk, drumstick, grapes, bitter guard, butter milk, coconut water, etc. should be taken
'''Vihara:''' Rest, fomentation, Lepa, Dhumapana, fasting
'''Apathya:'''
'''Ahara:''' Excessive and regular intake of horse gram and black gram pulses, virudha dhanya (sprouts), chillies and spices, sour and fermented foods like pickles, idali, dosa etc, heavy-to-digest foods like cheese, paneer, deep fried items etc., junk foods and fast foods, dadhi (curd), matsya (fish), meat of animals belonging to marshy areas (anupa mamsa), phanita, pinyaka (oil cake) aranala (sour gruel), excess water intake, excess alcohol intake and betel leaf chewing (tambula) should be avoided.
'''Vihara:''' Life style factors like anger, grief, excessive coitus; suppression of natural urges like defecation, micturition, lacrimation, hunger, thirst etc.; looking at minute objects, excessive weeping, excessive vomiting and suppression of vomiting, daytime sleep and awakening at night, shift duties, working on computer for continuous and longer duration and watching television for long time, sudden changes of temperatures, exposure to frequent change of hot and cold temperatures, exposure to dust and fumes, excessive sunlight exposure and smokingshould be avoided.
== Contemporary approach ==
<p style="text-align:justify;">The classical understanding of shiras aligns with the contemporary appreciation of the importance of the head in overall health. The head includes the ears, brain, forehead, cheeks, chin, eyes, nose, and mouth. These aid in various sensory functions such as sight, hearing, smell, and taste. Neurological disorders and conditions related to the head, such as headaches, are prevalent reasons for seeking medical assistance. Understanding shirasa in the modern context involves recognizing the intricate connections between the head and various physiological functions, including sensory perception, cognitive abilities, and vital life forces. The human head is an anatomical unit that consists of the skull, hyoid bone and cervical vertebrae. The term "skull" collectively denotes the mandible [lower jaw bone] and the cranium [upper portion of the skull that houses the brain].<ref name="ref9">Wikipedia Contributors. [2024, March 9]. Head. Retrieved March 11, 2018, from https://en.wikipedia.org/wiki/Head</ref></p>
== Research works done on shiras, physiology, anatomy, shiro-roga ==
Few research works related to shirasa and shiroroga:
<ol><li>A pilot study on clinical efficacy of ''Agnikarma'' and ''Pathyadi'' decoction (an Ayurvedic formulation) in the management of ''Ardhavabhedaka'' (migraine). <br/>This study concluded that Agnikarma along with Pathyadi decoction can be considered as an effective line of treatment to manage Ardhavabhedaka (migraine).</li>
<li>A concept of siravedha in shiroroga by Twinkal zala, hemangi shukla and aarti aghera. <br/>This study concluded that raktamokshana is one of the best treatment for Shiroroga.</li>
<li>Effects of Ayurveda interventions on acute pain and quality of life of a trigeminal neuralgia patient - A case report. <br/>In Ayurveda, TN is generally dealt with as the condition of Anantavata, which is a Vata-dominant Tridosha Shiroroga. The above study concluded that Ayurveda interventions used in the present case were found to be helpful in reducing the acute paroxysms of pain in CTN and improving the quality of life.</li>
<li>Efficacy of Sri Lankan Traditional Decoction of ''Katuwelbatu Deduru Katukadi'' in treatment of ''Kaphaja Shira Shula'' (Chronic Sinusitis).<br/>In this study it is concluded that decoction of Katuwelbatu Deduru Katukadiya, a Sri Lankan traditional decoction, can successfully be used in treatment of Kaphaja Shira Shula</li>
<li> Comprehensive review of shroshula in ayurveda reserve.<br/>This study concluded that Shirahshula is the most common disease, is mainly due to aggravation of vatadosha as well as tridosha. Panchakarma like- BrahanaNasya, Murdhnisneha (Shirodhara, Shiropichu, ShiroAbhyang & Shirobasti) Dhumapana, Kawal, Gandush, Taladharan, NetraTarpana are advised for treatment of shiroshula.</li></ol>
== Conclusion ==
<p style="text-align:justify;">In conclusion, shirasa is not merely a physical entity but a complex amalgamation of vital life forces, sensory organs, and cognitive functions. Ayurveda's classical approach to shirasa provides a holistic understanding that resonates with contemporary perspectives on neurological health. By recognizing the significance of dosha balance, preventive measures, and the intricate connections between the head and the entire body, individuals can strive to maintain the well-being of shiras for a healthier and more fulfilling life.</p>
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